Smiles by Natasha

Patient Resources

Teeth Whitening Clinic

Medical History Forms

    MEDICAL HISTORY: It is important to know details about your medical history as these could affect the success of your treatment and how we can provide this treatment safely for you. The information you provide is confidential and will be handled in accordance with our privacy policy.

    Are you receiving any medical treatment at present?

    Are you taking any medication or supplements?

    Have you been hospitalised in the last 12 months?



    Women, are you currently pregnant?


    Do you believe for any reason you need prophylactic antibiotics before dental appointments? Or do you currently take/have been advised to take prophylactic antibiotics before dental appointments?

    1. I have answered all questions to the best of my knowledge. Should further information be required, you have my permission to contact my medical practitioner, who may release such information to you.

    2. I agree to be responsible for payment of all services rendered on my behalf or my dependants. I understand that payment is due at the time of service unless other arrangements have been made. I also understand that if for any reason recovery of funds if required, costs involved will be at my expense.


      My dental professional has informed me that my teeth are discolored and could be treated by in-office whitening (also known as “bleaching”) of my teeth. This information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision about signing this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure.


      Zoom in-office tooth whitening is a procedure designed to lighten the color of my teeth using a combination of a hydrogen peroxide gel and a specially designed visible LED light lamp. The Zoom treatment involves using the gel and lamp in conjunction with each other to produce maximum whitening results in the shortest possible time. During the procedure, the whitening gel will be applied to my teeth and my teeth will be exposed to the light from the Zoom lamp for four (4) 15 minute sessions. During the entire treatment, a plastic retractor will be placed in my mouth to help keep it open and the soft tissues of my mouth (i.e., my lips, gums, cheeks and tongue) will be covered to ensure they are not exposed to either the gel or light. I will be provided a visible LED light filter for my eyes. After the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth. Before and after the treatment, the shade of my upper-front teeth will be assessed and recorded.


      I understand I may decide not to have the Zoom treatment at all. However, should I decide to undergo the treatment, I understand there are alternative treatments for whitening my teeth for which my dentist can provide me additional information. These treatments include:

      • Whitening Toothpastes/Gels

      • Other In-office Whitening Treatments

      • Take-Home Whitening Kits

      • Porcelain Crowns, Veneers or Composites

      treatment subsides within 24 hours, but in rare cases can persist for longer periods of time in susceptible individuals. People with existing sensitivity, recession exposing root surfaces, exposed dentin, untreated caries, cracked teeth, abfractions , oral tissue injury, open cavities, leaking fillings, or other dental conditions that cause sensitivity or allow higher penetration of the gel into the tooth may find that those condition increase or prolong tooth sensitivity or pain after Zoom treatment.

      Gum/Lip/Cheek Inflammation/Burn – Improper isolation during the whitening procedure may cause or result in (i) inflammation of your gums, lips or cheek margins due to exposure of a small area of those tissues to the whitening gel or the LED light, or (ii) a chemical burn due to whitening gel coming in contact with soft tissue. The inflammation or burn is usually temporary and will subside in a few days, but may persist longer and may result in significant pain or discomfort, depending on the degree to which the soft tissues were exposed to the gel or LED light.

      Dry/Chapped Lips – The Zoom treatment involves three, 15-minute sessions during which the mouth is kept open continuously for the entire treatment by a plastic retractor which covers the lips. This could result in dryness or chapping of the lips or cheek margins, which can be treated by application of lip balm, petroleum jelly or Vitamin E oil.

      Cavities or Leaking Fillings – Most dental whitening is indicated for the outside of the teeth, except for patients who have already undergone a root canal procedure. If any open cavities or fillings that are leaking and allowing gel to penetrate the tooth are present, significant pain could result. I understand that if my teeth have these conditions, I should have my cavities filled or my fillings redone before undergoing the Zoom treatment.

      Cervical Abrasion/Erosion – These are conditions which affect the roots of the teeth when the gums recede and they are characterized by grooves, notches and/or depressions that appear darker than the rest of the teeth, where the teeth meet the gums. These areas appear darker because they lack the enamel that covers the rest of the teeth. Even if these areas are not currently sensitive, they can allow the whitening gel to penetrate the teeth, causing sensitivity. I understand that if cervical abrasion/erosion exists on my teeth, these areas will be covered with dental dam prior to my Zoom treatment.


      I understand that almost all natural teeth can benefit from Zoom whitening treatment and significant whitening can be achieved in most cases. I understand however that Zoom treatment results may vary or regress due to a variety of circumstances. I understand that zoom whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials and that people with darkly stained yellow or yellow-brown teeth frequently achieve better results than people with gray or bluish-gray teeth. I understand that teeth with multiple colorations, bands, splotches, or spots due to tetracycline use or fluorosis do not whiten as well, may whiten unevenly, may require additional whitening, or may not whiten at all. Previous orthodontic treatments may cause teeth to whiten unevenly, either due to residual resin remaining on teeth or over polishing upon removal. Those with porcelain fused to metal crowns, amalgams, lingual bars or implants may feel excessive heat. I understand that teeth with many fillings and/or cavities may not lighten and are usually best treated by other non-bleaching alternatives. I understand that the Zoom Lamp emits visible LED light and all materials used in the isolation process, when properly used as directed, will block any exposures of soft tissues to this light. It is recommended that those currently treated for a serious illness or disorder (e.g. immune compromised, AIDS, increased photosensitivity etc) should consult a medical doctor before use.

      Zoom treatment is not recommended for pregnant or lactating women.

      I understand that the results of my Zoom Treatment cannot be guaranteed.

      I understand that in-office whitening treatments are considered generally safe by most dental professionals. I understand that although my dentist has been trained in the proper use of the Zoom whitening system, the treatment is not without risk. I understand that some of the potential complications of this treatment include, but are not limited to:

      Tooth Sensitivity/Pain – During the first 24 hours after Zoom treatment, some patients can experience some tooth sensitivity or pain. This is normal and is usually mild, but it can be worse in susceptible individuals. Normally, tooth sensitivity or pain following a Zoom Informed Consent for Zoom Tooth Whitening Treatment

      Relapse – After the Zoom treatment, it is natural for the teeth that underwent the Zoom treatment to regress somewhat in their shading after treatment. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents. Treatment usually involves wearing a take-home tray or repeating the Zoom treatment. I understand that the results of the Zoom treatment are not intended to be permanent and secondary, repeat or take-home treatments may be needed for me to maintain the tooth shade I desire for my teeth.

      The safety, efficacy, potential complications and risks of Zoom treatment can be explained to me by my dentist and I understand that more information on this will be provided to me upon my request. Since it is impossible to state every complication that may occur as a result of Zoom treatment, the list of complications in this form is incomplete.

      The basic procedures of Zoom treatment and the advantages and disadvantages, risks and known possible complications of alternative treatments have been explained to me by my dentist and my dentist has answered all my questions to my satisfaction.